Hepatocellular carcinoma in Budd-Chiari syndrome: enhancement patterns at dynamic gadolinium-enhanced T1-weighted MR imaging

Budd-Chiari syndrome in children: Challenges and outcome

Budd-Chiari syndrome (BCS) is an uncommon disease of the liver, characterised by obstruction of the hepatic venous outflow tract. The etiological spectrum of BCS as well as venous obstruction pattern show wide geographical and demographic variations across the globe. Compared to adults with BCS, children have primary BCS as the predominant etiology, earlier clinical presentation, and hence better treatment outcome. Underlying prothrombotic conditions play a key role in the etiopathogenesis of BCS, though work-up for the same is often unyielding in children. Use of next-generation sequencing in addition to conventional tests for thrombophilia leads to better diagnostic yield. In recent years, advances in radiological endovascular intervention techniques have revolutionized the treatment and outcome of BCS. Various non-invasive markers of fibrosis like liver and splenic stiffness measurement are being increasingly used to assess treatment response. Elastography techniques provide a novel non-invasive tool for measuring liver and splenic stiffness. This article reviews the diagnostic and therapeutic advances and challenges in children with BCS.

Budd-Chiari syndrome and its associated hepatocellular carcinoma: Clinical risk factors and potential immunotherapeutic benefit analysis

Background

Hepatocellular carcinoma (HCC) is a well-described complication of Budd-Chiari syndrome (BCS). However, the risk factors of BCS in developing HCC and clinical characteristics and imaging features of BCS-associated HCC is still to be determined.

Methods

Data from 113 consecutive patients with primary BCS in Qilu hospital were retrospectively studied. The clinical features of 12 HCC patients associated with BCS were also analyzed. Chi-square analysis was performed to analyze the differences in clinical characteristics. The treatment regime and CT imaging features of BCS-associated HCC were also illustrated.

Results

113 consecutive patients admitted to our hospital between January 2009 and June 2016 with a primary diagnosis of BCS were enrolled. 10.6% (12/113) was diagnosed with HCC. The BCS patients were mainly male gender with an average age of 49.2 years. Symptom duration longer than one year exhibited decreased serum ALT and AST and increased ascites ratio. BCS-associated HCC patients were presented with IVC block and stricture of the hepatic venous outflow tract. Patients with HCC were older and showed elevated serum AST and total bilirubin. Most nodules of HCC located in the right posterior lobe with heterogeneous enhancement during the arterial phase and washout during the delayed phase.

Conclusions

The results indicate that BCS patients with IVC block and stricture of hepatic venous outflow tract seem to be associated with HCC. BCS associated HCC nodules exhibited irregular and heterogeneous enhancement in the arterial phase and washout on the delayed phase.

Inferior vena cava obstruction in Budd-Chiari syndrome: a comparative study of rapid quantitative phase-contrast MRI and MRV

PURPOSE

The purpose of this study was to analyze inferior vena cava (IVC) obstruction in Budd-Chiari syndrome (BCS) using rapid quantitative phase-contrast (PC) magnetic resonance (MR) imaging and compare the diagnostic efficacy of PC and MR venography (MRV) to explore the clinical prospects of applying PC quantitative diagnosis in IVC obstruction in BCS.

MATERIALS AND METHODS

PC quantitative data and MRV qualitative data obtained in 35 DSA-recognized inferior vena cava obstruction in BCS patients and 35 patients with liver focal lesions found in physical examination were analyzed and compared.

RESULTS

The areas under the ROC curve for diagnostic parameters related to PC quantitative parameters, including stroke volume, forward flow volume, absolute stroke volume, mean flux, stroke distance, mean velocity (MV), and peak velocity, were 0.7767, 0.7788, 0.7747, 0.7665, 0.9143, 0.9159, and 0.8947, respectively. The sensitivity, specificity, and accuracy of MV in the diagnosis of IVC obstruction were 88.57%, 85.71%, and 87.14%, respectively. For IVC obstruction in BCS, there was no significant difference between the diagnostic efficacy of MV (one of the quantitative parameters of PC) and that of MRV (P = 0.0768).

CONCLUSION

PC can be used to diagnose IVC obstruction in BCS and improve the understanding of hemodynamics of IVC obstruction in BCS.

Non-contrast-enhanced MR angiography in the diagnosis of Budd-Chiari syndrome (BCS) compared with digital subtraction angiography (DSA): Preliminary results

Non-CE MRA techniques (true steady-state free-precession, SSFP) have been used effectively for the selective visualization of the portal venous system and inferior vena cava. Budd-Chiari Syndrome (BCS) encompasses a number of conditions that cause the obstruction of the hepatic outflow tract from the small hepatic veins to the junction of the inferior vena cava (IVC) and right atrium. The purpose of this study was to diagnose BCS with IVC obstruction using respiratory triggered three-dimensional (3D) true SSFP with T-SLIP and compare to digital subtraction angiography (DSA). The image acquisition of 3D true SSFP scans was successfully performed in 108 patients (≧2 score). The mean and SDs of the relative SNR and CNR were 55.96±2.32 and 30.72±1.56, respectively. Intergroup agreement for the detection of the 4 types (membranous obstruction, segmental occlusion, and membranous obstruction with a hole and segmental stenosis) of BCS with IVC obstruction was excellent between the Time-SLIP and the DSA. In conclusion, Time-SLIP for the detection of IVC obstruction BCS does not require the use of contrast. This procedure can achieve a high success rate, high accuracy rate and fine image quality for the diagnosis of IVC obstruction BCS.

Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is a rare and potentially life-threatening disorder characterized by obstruction of the hepatic outflow tract at any level between the junction of the inferior vena cava with the right atrium and the small hepatic veins. In the West, BCS is a rare hepatic manifestation of one or more underlying prothrombotic risk factors. The most common underlying prothrombotic risk factor is a myeloproliferative disorder, although it is now recognized that almost half of patients have multiple underlying prothrombotic risk factors. Clinical manifestations can be diverse, making BCS a possible differential diagnosis of many acute and chronic liver diseases. The index of suspicion should be very low if there is a known underlying prothrombotic risk factor and new onset of liver disease. Doppler ultrasound is sufficient for confirming the diagnosis, although tomographic imaging (computed tomography (CT) or magnetic resonance imaging (MRI)) is often necessary for further treatment and discussion with a multidisciplinary team. Anticoagulation is the cornerstone of the treatment. Despite the use of anticoagulation, the majority of patients need additional (more invasive) treatment strategies. Algorithms consisting of local angioplasty, TIPS and liver transplantation have been proposed, with treatment choice dictated by a lack of response to a less-invasive treatment regimen. The application of these treatment strategies allows for a five-year survival rate of 90%. In the long term the disease course of BCS can sometimes be complicated by recurrence, progression of the underlying myeloproliferative disorder, or development of post-transplant lymphoma in transplant patients.